Provider Demographics
NPI:1841333531
Name:CRANDALL, MARK WINTHROP (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WINTHROP
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 DEACON BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-2212
Mailing Address - Country:US
Mailing Address - Phone:410-356-2884
Mailing Address - Fax:410-833-8174
Practice Address - Street 1:11421 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1813
Practice Address - Country:US
Practice Address - Phone:410-356-2884
Practice Address - Fax:410-833-8174
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00235932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2494MWMedicare ID - Type Unspecified
MDD77683Medicare UPIN